Client Enrolment Form

Your Name

Your Address

Post Code

Contact Tel

Mobile Number

Your Email

Sex
MaleFemale

Date of birth

Occupation

Sports hobbies

Emergency contact details;

Name

Contact Tel

Mobile

Your Background and Your Health;

1. Does your Work / Sport involve any of the following? (please tick)
Sitting for long periodsBendingLifting heavy weightsDrivingStandingAny other repetitive actions

2. Will this be the first time you have practiced Pilates?
YesNo

If NO, have your previously attended : (please check)
StudioBody control Pilates Matwork classesOther Pilates matworkAt Home (Book, DVD)

Number of classes attended
0-55-1010-2020+

3. Has your doctor ever said that you have any sort of heart trouble or defect?
YesNo

4.Do you feel pain in your chest when you undertake physical activity?
YesNo

5. Are you, or could you be, pregnant now?
YesNo

6. Have you been pregnant in the last six months?
YesNo

7. If you have had a baby, how was it delivered?
Not ApplicableNormallyCaesareanNormally with intervention (e.g. foreceps)

8. Do you often get headaches?
YesNo

9. Do you loose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy?
YesNo

10. Do you have high blood pressure?
YesNo

11. Is your blood pressure:
NormalLow

12. Have you had major surgery in the last 10 years?
YesNo

13. Have you had minor surgery in the last two years?
YesNo

14. Do you suffer from asthma, diabetes or epilepsy?
YesNo

15. Have you ever been told that you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that may be made worse by exercising?
[checkbox q15 label_first use_label_element exclusive "Yes" No"]

16. Do you suffer from back or neck pain?
YesNo

17. Do you have pain or restricted movement in any other joints (e.g. hip, knee, ankle, shoulder)?
YesNo

18. Have you been diagnosed as hypermobile (excessive joint mobility)?
YesNo

19. Are there any movements that cause you pain?
YesNo

20. Are you taking any drugs or medication which may affect your ability to exercise?
YesNo

21. Have you been recommended to take up Pilates by a specialist practitioner?
YesNo

If Yes, by your;
GPChiropractorPhysiotherapistOsteopathOther

22. Do you hereby give us permission to contact them?
YesNo

If Yes then state their name and contact number.

Practitioner's Name:

Practice Telephone Number:

Please list any health problems you suffer, not already mentioned, that may affect your ability to exercise. If you have answered YES to any of question 3-21 above, we advise that you consult with your medical practitioner before you start Pilates classes. Please give further relevant details below, in confidence, to any questions ticked YES

Are there any factors that your teacher should be aware of that may prevent you from regularly attending classes (such as child care, lack of transport, shift work)?

Your Aims

What are the reasons for taking up Pilates?

What health or physical goals would you like to achieve over the next three months?

What longer term health or physical goals would you like to achieve over the next 12 months?